Clinical management of coronavirus disease 2019 (COVID-19) in pregnancy: recommendations of WAPM-World Association of Perinatal Medicine.

These guidelines follow the mission of the World Association of Perinatal Medicine, which brings together groups and individuals throughout the world with the goal of improving outcomes of maternal, fetal and neonatal (perinatal) patients. Guidelines for auditing, evaluation, and clinical care in perinatal medicine enable physicians diagnose, treat and follow-up of COVID-19-exposed pregnant women. These guidelines are based on quality evidence in the peer review literature as well as the experience of perinatal expert throughout the world. Physicians are advised to apply these guidelines to the local realities which they face. We plan to update these guidelines as new evidence become available.

Should Cesarean Scar Defect Be Treated Laparoscopically? A Case Report and Review of the Literature.

Several obstetric complications due to inappropriately healed cesarean scar such as placenta accreta, scar dehiscence, and ectopic scar pregnancy are increasingly reported along with rising cesarean rates. Furthermore, many gynecologic conditions, including abnormal uterine bleeding, pelvic pain and infertility, are imputed to deficient cesarean scar healing. Hysteroscopy is the most commonly reported approach for the revision of cesarean scar defects (CSDs). Nevertheless, existing evidence is inadequate to conclude that either hysteroscopy or laparoscopy is effective or superior to each other. Although several management options have been suggested recently, the laparoscopic approach has not been thoroughly scrutinized. We present a case and reviewed the data related to the laparoscopic repair of CSDs and compared the hysteroscopic and laparoscopic management options based on the data from previously published articles. As a result of our analyses, the laparoscopic approach increases uterine wall thickness when compared with the hysteroscopic approach, and both surgical techniques seem to be effective for the resolution of gynecologic symptoms. Hysteroscopic treatment most likely corrects the scar defect but does not strengthen the uterine wall; thus, the potential risk of dehiscence or rupture in subsequent pregnancies does not seem to be improved. Because large uterine defects are known risk factors for scar dehiscence, the repair of the defect to reinforce the myometrial endurance seems to be an appropriate method of treatment.

Comparison of transplacental treatment of fetal supraventricular tachyarrhythmias with digoxin, flecainide, and sotalol: results of a nonrandomized multicenter study.

BACKGROUND: Fetal tachyarrhythmia may result in low cardiac output and death. Consequently, antiarrhythmic treatment is offered in most affected pregnancies. We compared 3 drugs commonly used to control supraventricular tachycardia (SVT) and atrial flutter (AF). METHODS AND RESULTS: We reviewed 159 consecutive referrals with fetal SVT (n=114) and AF (n=45). Of these, 75 fetuses with SVT and 36 with AF were treated nonrandomly with transplacental flecainide (n=35), sotalol (n=52), or digoxin (n=24) as a first-line agent. Prenatal treatment failure was associated with an incessant versus intermittent arrhythmia pattern (n=85; hazard ratio [HR]=3.1; P<0.001) and, for SVT, with fetal hydrops (n=28; HR=1.8; P=0.04). Atrial flutter had a lower rate of conversion to sinus rhythm before delivery than SVT (HR=2.0; P=0.005). Cardioversion at 5 and 10 days occurred in 50% and 63% of treated SVT cases, respectively, but in only 25% and 41% of treated AF cases. Sotalol was associated with higher rates of prenatal AF termination than digoxin (HR=5.4; P=0.05) or flecainide (HR=7.4; P=0.03). If incessant AF/SVT persisted to day 5 (n=45), median ventricular rates declined more with flecainide (-22%) and digoxin (-13%) than with sotalol (-5%; P<0.001). Flecainide (HR=2.1; P=0.02) and digoxin (HR=2.9; P=0.01) were also associated with a higher rate of conversion of fetal SVT to a normal rhythm over time. No serious drug-related adverse events were observed, but arrhythmia-related mortality was 5%. CONCLUSION: Flecainide and digoxin were superior to sotalol in converting SVT to a normal rhythm and in slowing both AF and SVT to better-tolerated ventricular rates and therefore might be considered first to treat significant fetal tachyarrhythmia.

Foley catheter balloon endometrial ablation: successful treatment of three cases.

Endometrial ablation is one of the most effective methods for treatment of dysfunctional uterine bleeding (DUB). Balloon devices with circulating hot water inside or electrodes on the outer surface and radiofrequency-induced thermal destructors are the most recently introduced available tools for endometrial ablation. All of these methods are effective and simple but expensive technologies. The aim of this brief report is to evaluate the effectiveness and safety of a new, simple and money-saving procedure, namely foley catheter balloon endometrial ablation (FCBEA), for treatment of DUB. We present our experience with FCBEA performed on 3 women with severe meno-metrorrhagia unresponsive to medical therapy. There were no procedure-related complications with achievement of complete amenorrhea for a 19 months follow-up period. Although FCBA has yielded encouraging results, there exists a need for further investigation and validation on larger groups, before its universal application.

Analgesic efficacy of forced coughing versus local anesthesia during cervical punch biopsy.

BACKGROUND/AIMS: To compare local anesthesia and forced coughing in terms of subjective pain perception during cervical punch biopsy. METHODS: In this randomized controlled trial, 114 patients (mean age: 38.9 ± 9.0 years) scheduled for colposcopically directed cervical punch biopsy were randomly assigned to local anesthesia (n = 39), forced coughing (n = 39) and control (n = 36) groups. Pain perception was measured on a 10-cm visual analog scale (VAS) during the insertion of the speculum, injection of the local anesthetic to the cervix and the taking of the first cervical biopsy, as well as for the overall pain perceived during the entire procedure. RESULTS: Experimental groups were similar in age, gravidity, parity and prior curettage. The pain score obtained during the first cervical biopsy was significantly lower if local anesthesia was applied (p = 0.016). Groups were similar in other pain subscores. The duration of the entire procedure was significantly longer (p < 0.001) in the local anesthesia group, while it was not significantly different in forced coughing patients compared to controls. CONCLUSION: Local anesthesia, but not forced coughing, provides significant pain relief during cervical biopsy. Based on similarity to control data in terms of pain relief and shortening of the operation, forced coughing per se seems related neither to pain relief nor a faster cervical biopsy.

Comparison of oral nonsteroidal analgesic and intrauterine local anesthetic for pain relief in uterine fractional curettage: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: We sought to investigate the analgesic efficacy of oral dexketoprofen trometamol and intrauterine lidocaine in patients undergoing fractional curettage. STUDY DESIGN: A randomized, double-blind, placebo-controlled trial was conducted on 111 women. Subjects were randomly assigned into 4 groups to receive either 25 mg of dexketoprofen or similar-appearing placebo tablets and either 5 mL intrauterine 2% lidocaine or saline. The main outcome measure was the intensity of pain measured by a 10-cm visual analog scale. Pain scoring was performed prior to, during, and 30 minutes after the procedure. RESULTS: No statistically significant difference was found among the mean pain scores of women during the procedure in the dexketoprofen and saline, placebo and lidocaine, and dexketoprofen and lidocaine groups. The mean pain scores in all 3 groups revealed significant reduction when compared with placebo and saline combination (P = .001). CONCLUSION: Administration of intrauterine lidocaine or oral dexketoprofen appears to be effective in relieving fractional curettage associated pain. However, a combination of them does not work better in further reduction of pain.

Comparative study of a barbed suture, poliglecaprone and stapler in Pfannenstiel incisions performed for benign gynecological procedures: a randomized trial.

OBJECTIVE: To compare a novel barbed suture, poliglecaprone-25 suture and stapler in Pfannenstiel incisions performed for benign gynecological procedures. DESIGN: A randomized controlled non-inferiority trial with randomization in a 1:1:1 ratio. SETTING: Istanbul Dr. Lutfi Kirdar Kartal Research and Training Hospital, Department of Obstetrics and Gynecology. POPULATION: Patients between 18 and 45 years of age without prior lower abdominal incision and undergoing Pfannenstiel incisions for benign gynecological procedures. METHODS: A total of 117 female patients randomized into barbed (n = 39), poliglecaprone-25 (n = 39) and stapler (n = 39) groups according to suture type. Skin closure techniques were compared in terms of length of incision (cm), adverse events (wound dehiscence, incisional infection, seroma and hematoma), subjective pain scores, patient satisfaction and postoperative scar cosmesis. MAIN OUTCOME MEASURES. The difference between three suture materials in terms of postoperative incision pain, patient satisfaction and scar cosmesis. RESULTS: Skin closure techniques were similar in terms of length of incision (cm), adverse events and pain scores and Modified Hollander Cosmesis Score. Barbed (p < 0.001) and poliglecaprone-25 (p < 0.01) sutures were significantly better than staplers in terms of patient satisfaction. CONCLUSION: The three different methods of skin closure revealed comparable outcome except for a significant superiority of sutures to the stapler method in terms of patient satisfaction scores.

Laparoscopic cornuotomy in the management of an advanced interstitial ectopic pregnancy: a case report.

OBJECTIVE: To report the successful treatment of an advanced interstitial ectopic pregnancy via laparoscopic cornuotomy following treatment failure with methotrexate (MTX). CASE: A 28-year-old, gravida 3, para 0 woman with a history of successfully treated tubal pregnancy with medical therapy 2 years ago, presented with spotting bleeding and lower abdominal pain. Her initial beta-hCG level was 11706 mIU/ml and the transvaginal ultrasound examination showed an empty uterine cavity with a gestational sac 8 x 10 x 9 mm in diameter having no fetal pole or yolk sac, located just adjacent to the left uterine cornual region. She was introduced 50 mg of systemic MTX with the presumed diagnosis of interstitial pregnancy. Because the serum beta-hCG level raised to 18654 mIU/ml and a fetal pole with cardiac activity emerged on the ultrasound on the fourth day after MTX injection, laparoscopy was planned. The interstitial pregnancy was successfully treated via laparoscopic cornuotomy with the preservation of the uterus. CONCLUSION: In advanced interstitial pregnancies with high hCG levels, systemic MTX therapy is expected to be ineffective. Laparoscopic cornuotomy is a minimally invasive and effective method of treatment with the advantage of preserving future fertility.

Do asymptomatic patients require routine hemoglobin testing following uneventful, unplanned cesarean sections?

OBJECTIVE: To determine the clinical usefulness of routine postoperative hemoglobin testing after unplanned, uneventful cesarean sections in low-risk women without any signs or symptoms of anemia and to identify possible risk factors for hemorrhage. MATERIALS AND METHODS: Retrospective analysis of the charts of all women who underwent non-elective and uneventful cesarean section over 12 months was performed and demographic data, estimated blood loss at surgery, pre- and post-operative hemoglobin values, postoperative symptoms suggesting anemia, and incidence of transfusion were tabulated. Statistical analysis was done with Student t test and Mann-Whitney U test. RESULTS: A total of 2,450 women were delivered during the study period among whom 743 of them (30.3%) underwent cesarean section. Among the cesarean sections, 421 (56.6%) were found to be unplanned and uneventful operations performed in low-risk women with no postoperative signs or symptoms for anemia. The mean preoperative hemoglobin of the low-risk asymptomatic women was 11.7+/-1.99 g/dl, whereas it was 11.24+/-1.99 g/dl, postoperatively (P<0.001). In 72% of the patients, there was a drop in hemoglobin concentrations, whereas 24.5% experienced an increase and 3.5% showed no change, postoperatively. Only one woman experienced a drop of greater than 30% in hemoglobin concentration. Since the woman did not show any signs of hemodynamic instability or symptoms of anemia, she was not transfused. CONCLUSION: Our findings suggest that routine hemoglobin testing following uneventful, unplanned cesarean section neither change postoperative management nor determine the patients requiring blood transfusion.

Why Not Lose Faith in Science in the Fight Against Coronavirus.

BACKGROUND: One of the most vulnerable group to cope with the consequences of COVID-19 pandemic are women, particularly pregnant ones. OBJECTIVE: The aim of this article was to make review of the scientific literature to show clearly that pandemic is not so dangerous neither for mother nor her unborn and newborn children. RESULTS AND DISCUSSION: It should be stated that most of the scientific papers on COVID-19 are currently being conducted in a way that would probably be completely unacceptable to serious science in any other circumstances. Taking into account everything we have learned about the SARS-CoV-2 virus so far it comes as a surprise that there has not been a more intense scientific debate on whether the blind lockdown model, implemented by most national governments, was truly an appropriate response to the challenges posed by the pandemic. CONCLUSION: Deep analysis what science in perinatal medicine did assess and what it recommended to perinatal world it may be followed by principles that the research of the members of the Academy will not be the first to be published, but we certainly aim that the scientific evidence published by Academy is fast, reliable and implementable.

The effect of uterine fundal pressure on the duration of the second stage of labor: a randomized controlled trial.

OBJECTIVE: To determine the effect of uterine fundal pressure on shortening the second stage of labor and on the fetal outcome. DESIGN: Randomized controlled trial. SETTING: Teaching and research hospital. SAMPLE: One hundred ninety-seven women between 37 and 42 gestational weeks with singleton cephalic presentation admitted to the delivery unit. METHODS: Random allocation into groups with or without manual fundal pressure during the second stage of labor. MAIN OUTCOME MEASURES: The primary outcome measure was the duration of the second stage of labor. Secondary outcome measures were umbilical artery pH, HCO3-, base excess, pO2, pCO2 values and the rate of instrumental delivery, severe maternal morbidity/mortality, neonatal trauma, admission to neonatal intensive care unit, and neonatal death. RESULTS: There were no significant differences in the mean duration of the second stage of labor and secondary outcome measures except for mean pO2 which was lower and mean pCO2 which was higher in the fundal pressure group. Nevertheless, the values still remained within normal ranges and there were no neonates with an Apgar score <7 in either of the groups. CONCLUSION: Application of fundal pressure on a delivering woman was ineffective in shortening the second stage of labor.

Primary ovarian adenomyoma in a woman with endometrial polyp: a case report and review of the literature.

BACKGROUND: An adenomyoma presenting outside the uterus is an extremely rare entity and only three cases of primary ovarian adenomyoma have been reported up to date. CASE REPORT: We report the fourth case of ovarian adenomyoma in a 45-year-old woman with an endometrial polyp. Transvaginal ultrasonography revealed a solitary endometrial polyp with an enlarged left ovary which appeared heterogenous with isoechoic and mildly hyperechoic pattern. CONCLUSION: Total abdominal hysterectomy and bilateral salpingo-oopherectomy was performed and histologic examination revealed an adenomyoma arising primarily in the ovary.

Interobserver variability of modified Ferriman-Gallwey hirsutism score in a Turkish population.

OBJECTIVE: The aim of the study was to evaluate the interobserver variability of modified Ferriman-Gallwey (mFG) hirsutism scores on each body area in a Turkish population. DESIGN: A cross-sectional study of simultaneous mFG scoring design was used. Observers did not make any interview with the subjects and were masked to the previous score results. Analyses included percentage of agreement, kappa coefficients, the Bland and Altman plot, confidence intervals, minimum and maximum kappa coefficients. SETTING: The study was performed at a teaching and research hospital. PATIENTS: Hundred and twenty-one Turkish women without any complaints of excessive body hair were studied. INTERVENTIONS: Interventions included two special trained physicians, simultaneous and independent mFG scoring. MAIN OUTCOME MEASURES: The main outcome measures were mFG scores in each body area. RESULTS: Agreement analysis demonstrated that the scores of the two physicians were quite concordant. The mean kappa value for nine body area was 0.744 and the highest kappa values from the upper back and the lowest kappa values from the upper lip revealed kappa=0.847, kappa=0.585, respectively. The highest (upper lip) and the lowest (arm) mean range scores for the two researchers among the 9 areas were 1.46-1.55 and 0.17-0.12, respectively. Only 68.6 and 67.8% of the mFG scores observed by each of the two observers were equal or below 8. CONCLUSION: The mFG scoring system was found to be clinically useful. The upper lip was observed to have the highest score of androgen sensitive area of the body as well as the highest interobserver variability. The cut-off value to establish the diagnosis of hirsutism should be population-specific.

Anxiety scores before and after genetic sonogram.

OBJECTIVE: The value of genetic sonogram is controversial in low-risk population. The aim of our study was to compare the anxiety levels among women with high risk and low risk for fetal chromosomal/structural defects. MATERIALS AND METHODS: A total of 115 consecutive pregnant women were included. The anxiety levels were assessed by the use of Turkish version of the standardized state-trait-anxiety-inventory. Before and after genetic sonogram, state and trait-anxiety was measured. RESULTS: The mean state anxiety score before genetic sonogram was statistically, significantly higher than the mean score after the examination. Before genetic sonogram, the mean state-anxiety score of the women with high risk for fetal chromosomal/structural defects was significantly higher than the mean score of women with low risk. Following genetic sonogram, although the anxiety scores decreased, the scores of women with high risk still remained significantly higher than the scores of women with low risk and the anxiety scores significantly further increased among women with a positive minor or major ultrasound finding. CONCLUSION: Genetic sonogram presents an anxiety-inducing situation for the parents-to-be. The level of experienced anxiety was found to be proportional to the level of the perceived risk. Women with low risk for chromosomal/structural defects experienced lower anxiety than women with high risk. Following the examination, women with a negative result were found to have a significant reduction of anxiety and emotional relief whereas a positive test result led to a further increase in anxiety scores.

Fetal dysrhythmias.

Fetal cardiac dysrhythmias are potentially life-threatening conditions. However, intermittent extrasystoles, which are frequently encountered in clinical practice, do not require treatment. Sustained forms of brady- and tachyarrhythmias might require fetal intervention. Fetal echocardiography is essential not only to establish the diagnosis but also to monitor fetal response to therapy. In the last decade, improvements in ultrasound methodology and new diagnostic tools have contributed to better diagnostic accuracy and to a greater understanding of the electrophysiological mechanisms involved in fetal cardiac dysrhythmias. The most common form of supraventricular tachycardia - that caused by an atrioventricular re-entry circuit - should be differentiated from other forms of tachyarrhythmias, such as atrial flutter and atrial ectopic tachycardia. Ventricular tachycardia is rare in the fetus. Sustained tachycardias, intermittent or not, might be associated with the development of congestive heart failure and hydrops fetalis. Prompt treatment with either anti-arrhythmic drugs or delivery must be considered. Persistent fetal bradycardias associated with complete heart block are also potentially dangerous, whereas bradyarrhythmia due to blocked ectopy is well tolerated in pregnancy. Heart block can be associated with maternal anti-Ro/La autoantibodies or develop in fetuses with left atrial isomerism or with malformations involving the atrioventricular junction. The treatment of fetuses with immune-mediated heart block remains debatable. The use of antenatal steroid therapy is not widely accepted and there is concern over the risks and benefits of its use in the fetus. Direct fetal cardiac pacing has rarely been attempted.

The efficacy of laparoscopic presacral neurectomy in dysmenorrhea: is it related to the amount of excised neural tissue?

OBJECTIVE: To assess the correlation between the number of excised neural fibers and degree of pain relief following laparoscopic presacral neurectomy (LPSN). MATERIALS AND METHODS: In this before and after study, 20 patients with severe midline dysmenorrhea [Visual Analogue Scale (VAS) >80 mm] unresponsive to medical therapy were consecutively enrolled. All patients underwent LPSN. The superior hypogastric plexus was excised and sent for histologic confirmation. Two pathologists counted the number of neural fibers in the surgically removed tissue. VAS was used for pain assessment before and 2nd, 3rd, 6th, and 12th months after the operations. RESULTS: Out of the initial 20 patients undergoing LPSN, eight were excluded from the final analysis due to intraoperative diagnosis of endometriosis; therefore, the remaining 12 patients were evaluated. The pain scores significantly decreased at each follow-up visit compared with the preoperative period (p=0.002). The pathologists, who were blinded, reported the median (minimum-maximum) neural fiber count as 46 (20-85) and 47 (18-83). No significant correlation was demonstrated between the number of excised neural fibers and the amount of pain relief following LPSN. CONCLUSION: LPSN is an effective surgical procedure to control primary dysmenorrhea. Our preliminary results revealed that the degree of pain relief in cases of severe midline dysmenorrhea was not related to the amount of excised neural tissue in LPSN.

Does preeclampsia have any adverse effect on fetal heart?

OBJECTIVE: To determine whether preeclampsia causes fetal cardiac cell damage by assessing umbilical artery NT-proBNP, cardiac troponin I and homocysteine. METHODS: A cross-sectional study with 73 fetuses between 26 and 40 weeks of gestation was performed. Thirty-three healthy mothers' fetuses were control group (Group I). While 12 mildly pre-eclamptic mothers' fetuses constituted Group II, 28 fetuses of severe pre-eclamptic mothers were Group III. RESULTS: Umbilical cord mean NT-proBNP levels of Group I, II and III are 520.8 ± 404.5 pg/ml; 664.2 ± 215.9 pg/ml; and 1932.8 ± 2979.5 pg/ml, respectively (p = 0.0001). The number of neonates with NT-proBNP > 500 pg/mL that indicates severe cardiac damage is higher in Group III (p = 0.001). The mean homocysteine levels are also statistically significantly higher in Group III. Cardiac troponin I levels are not different between the groups (p = 0.46). CONCLUSION: Increased NT-proBNP and homocysteine might not only indicate some degree of in-utero cardiac cell damage but also feto-placental endothelial injury in the fetuses of severe pre-eclamptic mothers. Our finding that shows no evidence of correlation between cardiac troponin I levels with cell damage and endothelial injury requires further research.